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| Gonorrhea Classification and external resources |
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| ICD-10 | A54 |
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| ICD-9 | 098 |
Gonorrhea (also gonorrhoea), caused by the bacteria Neisseria gonorrhoeae, is a common sexually transmitted disease. In the US, its incidence is second[1] only to chlamydia.[2]
Non-genital sites in which it thrives are in the rectum, the throat (oropharynx), and the eyes (conjunctiva). The vulva and vagina in women are usually spared because they are lined by stratified epithelial cells—in women the cervix is the usual first site of infection. Gonorrhea typically spreads during sexual intercourse. It can also be vertically transmitted, where infected mothers can pass gonorrhea to their newborn infants during delivery. This causes conjunctivitis (eye infections) which, if left untreated, can lead to blindness. As prophylaxis against this, many countries routinely treat infants with eyedrops of erythromycin at birth. [3]
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Symptoms
The incubation period is 1 to 10 days with most symptoms occurring between the second and fifth days after being infected. A small number of people may be asymptomatic for up to a lifetime. Between 30–60% of people with gonorrhea are asymptomatic or have subclinical disease.[4] Women may complain of vaginal discharge, difficulty urinating (dysuria), projectile urination, off-cycle menstrual bleeding, or bleeding after sexual intercourse. The cervix may appear anywhere from normal to the extreme of marked cervical inflammation with pus. Possibility of increased production of male hormones is common in many cases. Infection of the urethra (urethritis) causes little dysuria or pus. The combination of urethritis and cervicitis on examination strongly supports a gonorrhea diagnosis, as both sites are infected in most gonorrhea patients. Gonorrhea is caused by the Neisseria gonorrhoeae bacteria. The infection is transmitted from one person to another through vaginal, oral, or anal sexual relations, though transmission occurs rarely with "safe sex" practices of condom usage with lubrication.
Men have a 20% chance of getting the infection by having sexual relations with a woman infected with gonorrhea. Women have a 50% chance of getting the infection by having sexual relations with a man infected with gonorrhea. An infected mother may transmit gonorrhea to her newborn during childbirth, a condition known as ophthalmia neonatorum.[5]
Less advanced symptoms, which may indicate development of pelvic inflammatory disease (PID), include cramps and pain, bleeding between menstrual periods, vomiting, or fever. It is not unusual for men to have asymptomatic gonorrhea. Men may complain of pain on urinating and thick, copious, urethral pus discharge (also known as gleet) is the most common presentation. Examination may show a reddened external urethral meatus. Ascending infection may involve the epididymis, testicles or prostate gland causing symptoms such as scrotal pain or swelling. Instances blurred vision in one eye may occur in adults.
Complications
In men, inflammation of the epididymis (epididymitis), prostate gland (prostatitis) and urethral structure (urethritis) can result from untreated gonorrhea[5].
In women, the most common result of untreated gonorrhea is pelvic inflammatory disease, a serious infection of the uterus that can lead to infertility. Further on, perihepatitis may develop[5]. This rare complication is associated with Fitz-Hugh-Curtis syndrome. Additionally, septic arthritis in the fingers, wrists, toes, and ankles is also common. This should be evaluated promptly with a culture of the synovial fluid, blood, cervix, urethra, rectum, skin lesion fluid, or pharynx. The underlying gonorrhea should be treated; if this is done then usually a good prognosis will follow.
Treatment
Antibiotics
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Antibiotics that may be used to treat gonorrhea include:
- Amoxicillin 2 g plus probenecid 1 g orally
- Ampicillin 2 to 3 g plus probenecid 1 g orally
- Azithromycin 2 g orally
- Cefixime 400 mg orally
- Cefotaxime 500 mg by intramuscular injection
- Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally
- Cefpodoxime (Vantin) 400 mg orally
- Ceftriaxone (Rocephin) 125 to 250 mg by intramuscular injection
- Ciprofloxacin 500 mg orally
- Levofloxacin 250 mg orally
- Ofloxacin 400 mg orally
- Spectinomycin 2 g by intramuscular injection
These drugs are all given as a single dose.
The level of tetracycline resistance in Neisseria gonorrhœae is now so high as to make it completely ineffective in most parts of the world.
The fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) cannot be used in pregnancy. It is important to refer all sexual partners to be checked for gonorrhea to prevent spread of the disease and to prevent the patient from becoming re-infected with gonorrhea. Patients should also be offered screening for other sexually transmitted infections. In areas where co-infection with chlamydia is common, doctors may prescribe a combination of antibiotics, such as ceftriaxone with doxycycline or azithromycin, to treat both diseases.
Penicillin is ineffective at treating rectal gonorrhea: this is because other bacteria within the rectum produce β-lactamases that destroy penicillin. All current treatments are less effective at treating gonorrhea of the throat, so the patient must be rechecked by throat swab 72 hours or more after being given treatment, and then retreated if the throat swab is still positive.
Although gonorrhea usually does not require follow-up (with the exception of rectal or pharyngeal disease), patients are usually advised to phone for results five to seven days after diagnosis to confirm that the antibiotic they received was likely to be effective. Patients are advised to abstain from sex during this time.
Drug resistant strains are known to exist.
United States recommendations
The United States does not have a federal system of sexual health clinics, and the majority of infections are treated in family practices. A third-generation cephalosporin antibiotic such as ceftriaxone is recommended for use in most areas. Since some areas such as Hawaii and California have very high levels of resistance to fluoroquinolone antibiotics (ciprofloxacin, ofloxacin, levofloxacin) they are no longer used empirically to treat infections originating in these areas.
Since 1993, fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have been used frequently in the treatment of gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy. Beginning in 2000, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii); in 2002, this recommendation was extended to California (2). In 2004, CDC recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM). On the basis of the most recent evidence, CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease (PID).[6] Consequently, only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea.citation needed The Center for Disease Control has recently (April 2007) updated treatment guidelines.[7]
Antibiotics can successfully cure gonorrhea in adolescents and adults. However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States, and successful treatment of gonorrhea is becoming more difficult. Because many people with gonorrhea also have chlamydia, another sexually transmitted disease, antibiotics for both infections are usually given together. Persons with gonorrhea should be tested for other STDs. It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.
United Kingdom recommendations
In the United Kingdom, the majority of patients with gonorrhea are treated in dedicated sexual health clinics. The current recommendation is for ceftriaxone or cefixime as first line therapy; no resistance to either drug has yet been reported in the UK. Levels of spectinomycin resistance in the UK are less than 1%, which would make it a good choice in theory, but intramuscular spectinomycin injection is very painful.
Azithromycin (given as a single dose of 2 g) has been recommended if there is concurrent infection with chlamydia. However, since 2000, the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) has gathered data on drug resistant strains of gonorrhoea in the UK. In 2005, 2.2% of cases were azithromycin resistant and in some regions of the UK this extended to 5% of cases. The mainstay of treatment now is a cephalosporin with azithromycin (to cover chlamydia). A single dose of oral ciprofloxacin 500 mg is effective if the organism is known to be sensitive, but fluoroquinolones were removed from the UK recommendations for empirical therapy in 2003 because of increasing resistance rates. In 2005, resistance rates for ciprofloxacin were 22% for the whole of the UK (42% for London, 10% for the rest of the UK).[8]
Historically
Historically it has been suggested that mercury was used as a treatment for gonorrhea. Surgeons tools on board the recovered English warship the Mary Rose included a syringe that, according to some, was used to inject the mercury via the urinary meatus into any unfortunate crewman suffering from gonorrhea. Silver nitrate was one of the widely used drugs in the 19th century, but it became replaced by Protargol. Arthur Eichengrün invented this type of colloidal silver which was marketed by Bayer from 1897 on. The silver-based treatment was used until the first antibiotics came into use in the 1940s.[9][10]
Prevalence
"Gonorrhea is a very common infectious disease. The CDC estimates that more than 700,000 persons in the United States get new gonorrheal infections each year. Only about half of these infections are reported to CDC. In 2004, 330,132 cases of gonorrhea were reported to the CDC. After the implementation of a national gonorrhea control program in the mid-1970s, the national gonorrhea rate declined from 1975 to 1997. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113.5 per 100,000 persons."[11]
Slang terms
Gonorrhea is also commonly known by the slang term the clap.
Suggested etymology:
- Reference to a traditional treatment used to clear the blockage in the urethra from gonorrheal pus, where the penis would be "clapped" on both sides simultaneously.citation needed
- Reference to the painful sting in the male urethra, which feels like the sting of a clap (as in clapping hands) when infected with the disease.
- From the old French word "clapoir", meaning sexual sore. This word was derived from the old French word "clapier", meaning "brothel".
The term the clap was replaced with the similar sounding the jack in the 1975 AC/DC song The Jack, which used the metaphor of playing cards and poker as sexual innuendo in the original LP version. However, live recordings of the song make direct references to the disease.
References
- ^ "CDC - STD Surveillance - Gonorrhea". Retrieved on 2008-08-21.
- ^ "CDC Fact Sheet - Chlamydia". Retrieved on 2008-08-21.
- ^ "Erythromycin ointment for ocular prophylaxis of neonatal chlamydial infection". Retrieved on 2008-07-14.
- ^ YT van Duynhoven (1999). "The epidemiology of Neisseria gonorrheae in Europe". Microbes and Infection 1 (6): 455–464. doi:. PMID 10602678.
- ^ a b c Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 705-706 ISBN 978-1-4160-2973-1
- ^ "CDC Update to Sexually Transmitted Treatment Guidelines". Retrieved on 2008-08-21.
- ^ "CDC STD Treatment Regimens". Retrieved on 2008-08-21.
- ^ Health Protection Agency. "The gonococcal resistance to antimicrobials surveillance programme: Annual report 2005" (PDF). Retrieved on 2006-10-28.
- ^ Max Bender (1898). "Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol)". Archives of Dermatological Research 43 (1): 31–36. doi:.
- ^ "MedlinePlus - Neonatal Conjunctivitis". Retrieved on 2008-08-28.
- ^ "Gonorrhea - CDC Fact Sheet". Retrieved on 2008-07-31.
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- This page was last modified on 4 September 2008, at 02:13.
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